Urinary Incontinence: An Epidemic?

Transcription

1 Urinary Incontinence: An Epidemic? Release Date: 08/09/2011 Expiration Date: 08/09/2014 FACULTY: Tamara Dickinson, RN, CURN, CCCN, BCB-PMD Senior Research Nurse, Continence and Voiding Dysfunction UT Southwestern Medical Center, Dallas, TX FACULTY AND ACCREDITOR DISCLOSURE STATEMENTS: Tamara Dickinson has no actual or potential conflict of interest in relation to this program. ACCREDITATION STATEMENT: Pharmacy PharmCon Inc is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. Program No.: H01-P Credits: 1 contact hour, 0.1 CEU Nursing Pharmaceutical Education Consultants, Inc. has been approved as a provider of continuing education for nurses by the Maryland Nurses Association which is accredited as an approver of continuing education in nursing by the American Nurses Credentialing Center s Commission on Accreditation. Program No.: N-684 Credits: 1 contact hour, 0.1 CEU

2 TARGET AUDIENCE: This accredited program is targeted to pharmacists and nurses practicing in hospital and community pharmacies. Estimated time to complete this monograph and posttest is 60 minutes. DISCLAIMER: PharmCon, Inc does not view the existence of relationships as an implication of bias or that the value of the material is decreased. The content of the activity was planned to be balanced and objective. Occasionally, authors may express opinions that represent their own viewpoint. Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient or pharmacy management. Conclusions drawn by participants should be derived from objective analysis of scientific data presented from this monograph and other unrelated sources. Program Overview: To provide pharmacists and nurses with an understanding of urinary incontinence and its prevalence so as to be better prepared in their practice. OBJECTIVES: After completing this program, participants will be able to: 1. Define three types of urinary incontinence. 2. List two types of treatment for urinary incontinence. 3. State three reasons for transient incontinence

3 Introduction Urinary Incontinence is a significant global, social and public health concern and the leading cause of long term care facility placement in the United States, affecting 50% of nursing home residents. Many myths surround this disease as well as its diagnosis and management. The healthcare professional s knowledge of urinary incontinence and their willingness to discuss it is vital for a patient s diagnosis and subsequent treatment. It is a common misconception that incontinence is a normal part of aging and is something that must be lived with. There are many treatment options available and are not all surgical. A Case Study Millie is a 72 year old female patient on the orthopedic unit who has recently undergone a hip replacement. Mobility is obviously a significant concern for her in her care post-operatively. She is otherwise a very healthy and vibrant older woman. After the a foley catheter is removed she becomes incredibly anxious and almost despondent. Upon further questioning, she admits she is concerned about her bathroom habits while in the hospital. She reports that she has severe urgency and frequency of urination. She states that she voids about times during the day and at least 4 times at night. She also states she often has to rush to the toilet in order to prevent accidents. She attributes this to her age. Her nurse realizes Realizing this is not normal and looks back at her urinary output and questions her regarding her fluid intake. She actually confides in the nurse that she limits her fluid intake to avoid her symptoms. These findings are discussed with her surgeon. He doesn t seem to be very concerned, but he orders a Urology consult. Dickinson Urinary Incontinence Page 1

4 Prevalence and Misconceptions It is estimated 17 million adults in the United States experience urinary incontinence 1 and that it affects about 200 million people worldwide 2. One population based prevalence study done in 2005 showed 45% were affected 4. Merriam-Webster defines an epidemic as affecting or tending to affect a disproportionately large number of individuals within a population, community, or region at the same time and as excessively prevalent 3. One might ask if urinary incontinence is an epidemic. Urinary incontinence is defined by the International Continence Society as the involuntary leakage of urine 10. Urinary incontinence has a significant impact on society not to mention personal hygiene and quality of life. It is distressing and disabling and affects social, psychological, occupational, domestic, physical and sexual life. The incidence of urinary incontinence is felt to be under-reported for reasons of embarrassment or that it is a normal part of aging and there is no effective treatment 1. Urinary incontinence is never a normal part of aging, however Newman states that urinary incontinence affects people of all age groups but is seen most often in older adults 1. There are some conditions prevalent in the older populations that do predispose them to urinary incontinence and lower urinary tract dysfunction. Today there are many effective treatments for the properly evaluated and diagnosed patient. Unfortunately, many who come forward with complaints of urinary incontinence are told to live with it. The Simon Foundation 6, a non-profit organization dedicated to promoting continence and changing lives developed an anti-stigma campaign to aid in bringing incontinence out of the closet 7. Nationwide consumer research on the topic of incontinence was conducted by the National Association for Continence 8 and published in 2005 in Urologic Nursing 12. Some astonishing highlights from that article are: Dickinson Urinary Incontinence Page 2

5 One third of men and women ages believe that urinary incontinence is a part of aging to accept Consumer research shows 1 in 4 women over the age of 18 experience episodes of leaking involuntarily Two thirds of men and women ages have never discussed bladder health with their doctor Only 1 in 8 Americans who have experienced urinary incontinence have been diagnosed Two thirds of individuals who experience urine loss do not use any treatment or product to manage their incontinence. The problem is not just consumer or patient awareness. Healthcare professionals of all disciplines should be open to discussing this problem with their patients. Palmer s early work in urinary incontinence revealed that 20% of nurses polled thought that other nursing staff would be resistant or indifferent to continence programs 5. Urinary incontinence clearly affects the lives of many and should be a concern to anyone who provides health care 9. The annual direct costs for the management of urinary incontinence in the United States are estimated at $ 12.4 billion for women and $ 3.8 billion for men 11. Urinary incontinence is such a significant and costly health issue that in 2001 the World Health Organization supported the 2 nd International Consultation on Incontinence (ICI). Participants in this meeting were chosen in order to create an authoritative multidisciplinary group to review evidence based medicine to document the current state of the science and develop guidelines and healthcare policies 13. Since that time another group was convened for the 3 rd International Consultation on Incontinence in Dickinson Urinary Incontinence Page 3

6 Anatomy and Physiology of the Lower Urinary Tract The lower urinary tract is made up of the bladder and the urethra. The micturition cycle or the storage and evacuation of urine is the primary functions of the lower urinary tract. Proper lower urinary tract function is dependent on anatomic integrity and intact neuronal pathways. Factors affecting lower urinary tract function can be disruption in the anatomic integrity such as pelvic organ prolapse or radical prostatectomy. Neurogenic lower urinary tract dysfunction can be caused by disorders such as spinal cord injuries, cerebrovascular accidents, multiple sclerosis and Parkinson s disease. The bladder, a hollow muscular organ, sits just behind the pubis symphysis. The bladder is under sympathetic and parasympathetic nervous system control. The sympathetic nervous system relaxes the bladder muscle and contracts the urinary sphincter to prevent urine from leaving the bladder. The parasympathetic nervous system stimulates the bladder to contract and relaxes the sphincters. The bladder is comprised of three layers: an inner mucosal layer or urothelium, a central muscular layer and an outer fatty layer. The muscular layer is made of smooth muscle and is called the detrusor muscle. This muscle should be elastic and stretch easily, or accommodate, to being filled with little or no change in bladder pressure. In a normal voluntary voiding event the detrusor muscle contracts to empty urine while the external urinary sphincter and the pelvic floor musculature relax. The voluntary initiation of urination is accomplished by a complex set of reflexes originating from the brain stem. Newman states The pudendal nerve is part of the voluntary nervous system and is involved the innervation of the external urinary sphincter, the external anal sphincter and the pelvic and urogenital muscles 1. Unfortunately the pudendal nerve can be subject to damage in childbirth and pelvic surgery. Dickinson Urinary Incontinence Page 4

7 Types of Urinary Incontinence The most common types of urinary incontinence include stress urinary incontinence (SUI), urge urinary incontinence (UUI) and mixed urinary incontinence (MUI). Stress urinary incontinence (SUI) is urine leakage occurring with increased abdominal pressure, such as coughing, sneezing or lifting something heavy. This can often be the result of loss of support of the ureterovesical junction 1. Risk factors for stress urinary incontinence are believed to be things that continually cause an increase in abdominal pressure and/or can cause damage to the outlet and supporting structures. These can be excessive weight, constipation, multiparity, and radical pelvic surgery 1. It is also believed that a hypo estrogenic state of the urogenital area can contribute to all forms of urinary incontinence. Urge urinary incontinence (UUI) is urine loss associated with an urgent need to urinate. This leakage is caused by abnormal and involuntary contractions of the bladder muscle, called the detrusor muscle. Overactive bladder (OAB) is associated with these abnormal detrusor contractions that do not cause leakage or are not strong enough to overcome the bladder outlet. Symptoms of OAB and UUI include urinary frequency, urinary urgency and nocturia. Urinary urgency is the complaint of a sudden compelling desire to pass urine which is difficult to defer 10. Nocturia is the complaint that the individual has to wake at night one or more times to void 10 not that they are awake for another reason and decide to empty their bladder. People with OAB and UUI often complain these urges being overwhelming just as they arrive at home. This is referred to as the key in the lock syndrome or the garage door syndrome 1. These patients also report an activity called toilet mapping. This means they know where every toilet is in the stores, restaurants and other places they frequent 1. OAB and UUI can also be related to involuntary detrusor contractions caused by neurologic Dickinson Urinary Incontinence Page 5

8 disorders. Mixed urinary incontinence (MUI) is when there is a combination of symptoms of both stress and urge urinary incontinence. Other less common types of urinary incontinence include overflow incontinence and functional incontinence. Overflow incontinence occurs when the bladder is never really empty and as the bladder continues to be filled by the kidneys some spills off the top or leakage occurs. The International Continence Society s Standardization of Lower Urinary Tract Terminology Committee feels this condition implies chronic retention of urine 10. This can be caused by chronic obstruction, neuropathy or nervous system injury. This potential type of urinary incontinence makes the evaluation of the post-void residual very important. Functional incontinence occurs when patients have normal lower urinary tract function but frankly cannot make it to the toilet in time. Reasons for functional incontinence can include restricted mobility or dexterity, environmental barriers, mental or psychosocial disabilities or medications that affect any of the above. Assessment and Evaluation of Incontinence So how is urinary incontinence evaluated? Newman feels that bladder diaries (or voiding diaries) and measurement of a post-void residual are the most basic vital components of the assessment 1. Transient urinary incontinence (particularly in the elderly) must be ruled out and can be caused by dehydration, delirium, restricted mobility, acute urinary retention, urinary tract infection, stool impaction, polypharmacy, and polyuria. Evaluation for potential risk factors needs to be considered (Table 1) Dickinson Urinary Incontinence Page 6

9 Table 1 Elderly females Multiparity Menopause Pelvic floor muscle weakness Depression Impaired mental status Impaired mobility Polypharmacy Pelvic surgery Smoking Obesity Neurologic diagnoses The clinical assessment must include an in depth history and physical. The patient s history should include questioning regarding their mental status, bowel history and habits, all medical and surgical history, urinary habits and any potential for neurologic disorders. Particularly in women, the physical exam should include a pelvic exam evaluating the pelvic floor muscles and pelvic floor support (or the presence or absence of pelvic organ prolapse). A functional and environmental assessment is often helpful. A urinalysis should be done to rule out the possibility of infection. Urodynamics are also helpful in identifying and clarifying the type of urinary incontinence and lower urinary tract dysfunction. Urodynamics is a pressure measurement testing done via catheter insertion and is the only functional diagnostic testing of the bladder and lower urinary tract. Treatment Options Fortunately today treatment options for urinary incontinence vary greatly and do not always mean surgery. Dietary changes can often help with lower urinary tract symptoms. One should consume adequate fluids. Too few fluids can cause concentrated urine that is irritating to the bladder mucosa while too many fluids obviously increases urinary output. Adequate fluid Dickinson Urinary Incontinence Page 7

10 intake is ml/day in adults and ml/day in older adults 1. Decreasing the intake of known bladder irritants can also decrease lower urinary tract symptoms. These include caffeine, carbonated beverages, alcohol, citrus fruits and juices, spicy foods, tomato based products and artificial sweeteners. Managing constipation can also have a significant effect on urinary incontinence 1. Simple things such as evening fluid restrictions and elevating the lower extremities in the evening can aid in the management of nocturia. Toileting programs and bladder retraining programs are behavioral methods that target either restoration or maintenance of bladder function. Scheduled or timed voiding is used as a form of habit training;, however, prompted voiding reinforces appropriate toileting 1. Scheduled or timed voiding is when the caregiver takes the patient to the toilet at a scheduled time. Prompted voiding is the caregiver going to the patient and asking if they need to go to the toilet, prompting appropriate toileting. Both these methods are found to be useful in continence programs in long-term care facilities. Bladder retraining teaches one to resist the sensation of urgency and postpone voiding. This is particularly affective in the management of overactive bladder. Another form of bladder retraining would be to have someone with obsessive toileting urinate based on the clock alone. All of these behavioral modification techniques provide the patient with examination and change of voiding patterns 10. Newman states, In the late 1940 s, Dr. Arnold Kegel implemented a comprehensive program of progressive contractions of the pelvic floor muscles 1. Today, pelvic muscle training has grown into a complex therapy involving highly trained nurses teaching behavioral modification and appropriate use of pelvic floor muscle rehabilitation. Pelvic muscle rehabilitation employs the use of pelvic muscle exercises as repetitive and selective voluntary contractions and relaxation of specific pelvic floor muscles. This can increase support at the outlet of the bladder and aids in techniques to suppress urgency. Improvement persists over time Dickinson Urinary Incontinence Page 8

11 but requires a motivated patient willing to do exercises per day at a minimum. It is also important to ensure that there is adequate assessment of pelvic floor muscle contractions for isolation of pelvic floor muscles and performance technique. Patients should be given both written and verbal instructions of their exercise programs. In addition, computer assisted biofeedback and electrical stimulation can help strengthen and isolate the pelvic floor muscles. A specific technique for stress urinary incontinence involves teaching the patient to squeeze (or perform a pelvic floor muscle contraction) before the cough or sneeze. This also works well if the patient is lifting something heavy. This technique requires a great deal of practice and adequate pelvic floor muscle strength. Urge suppression techniques, however, are much easier to master. This involves rapid quick squeezes of the pelvic floor muscles to interrupt the urge from the brain. Overflow incontinence, again implies chronic retention of urine and usually necessitates drainage of the bladder by means of intermittent self catheterization or indwelling catheter. Functional incontinence may be addressed by simply altering the environmental factors. A patient with poor dexterity may need to alter their clothing so that it is easier to remove. A bedside commode may prevent incontinence as well as a fall while trying to navigate to the toilet in the middle of the night. Therapy for mixed incontinence is aimed at the most troublesome symptoms and is often a combination of treatment. Pharmacologic therapy with antimuscarinics for overactive bladder (OAB) and urge urinary incontinence (UUI) is effective as they decrease involuntary bladder contractions. Antimuscarinic (or anticholinergic) therapy blocks acetylcholine that stimulates the receptors in the detrusor muscle, causing it to contract. Antimuscarinics block acetylcholine receptors in the bladder urothelium causing an increase in how full the bladder needs to be to stimulate an involuntary bladder contraction. This, in theory, increases the bladder capacity therefore Dickinson Urinary Incontinence Page 9

12 decreasing urinary frequency. Antimuscarinic therapy has stood the test of time for the management of OAB and UUI. However, one issue is that of tolerability versus real efficacy of the drugs. Muscarinic or cholinergic receptors are not only found in the bladder making side effects potentially influence the long-term use of these medications and this is a condition that will typically require long-term therapy and/or management. Muscarinic receptors can be found in the brain, salivary glands, cardiac smooth muscle, gastrointestinal tract smooth muscle and the ciliary muscle. Adverse effects of antimuscarinic therapy can include cardiac changes, urinary retention, CNS effects, and most commonly dry mouth, constipation and blurred vision. The potential to cross the blood brain barrier depends on the drug s molecular weight, its lipophilicity and its charge. 1 The CNS effects and the potential of the drug crossing the blood brain barrier should be monitored closely in the elderly and anyone in whom mental status changes are frequent (such as patients with Multiple Sclerosis or history of cerebrovascular accident). There are many options currently available on the market. These drugs include oxybutynin (both immediate and extended release as well as a transdermal patch and gel preparations), tolterodine (both immediate and extended release), solifenacin, fesoterodine and darifenacin. Trospium chloride is also available. Oxybutynin has been used for over 30 years. 1 The immediate release form is the oldest available and due to its rapid absorption is associated with a high incidence of intolerable side effects (severe dry mouth, severe constipation and/or blurred vision). An osmotic drug delivery system allows slower absorption of the oxybutynin and a decrease in the incidence of side effects. Oxybutynin is also available in a transdermal patch and gel preparation. These have shown evidence of decreased side effects largely believed to be due to lack of absorption via the Dickinson Urinary Incontinence Page 10

13 GI tract. Oxybutynin should be used with great care in elderly patients because of possible cognitive side effects likely due to its lipophilicity. Solifenacin is believed to be more selective of the M 3 receptors making it more bladder specific and had a lower rate of dry mouth and constipation in its clinical trials. Darafenacin is believed to be similar. Tolterodine is available in an immediate release and extended release formula. It is a tertiary amine that metabolizes to an active metabolite. Fesoterodine is the latest OAB drug to be released on the market and it is even more rapidly changed to the active metabolite of tolterodine. Trospium chloride is a quaternary ammonium and due to its hydrophilic state is unlikely to cross into the brain and cause potential memory changes. This can be of particular interest to those treating the frail elderly. One needs to keep in mind that although these drugs are intended for the same use, patients are all different and may respond either positively or negatively in different ways.unfortunately, pharmacotherapy for stress urinary incontinence has limited options with limited efficacy. In post-menopausal women, topical hormone replacement therapy may benefit those with mild symptoms. In the past α- adrenergic agonists (such as pseudoephedrine) has been used (off-label) to help tighten the bladder outlet. Surgical therapy is still considered the gold standard for the management of stress urinary incontinence. The aim of this surgical intervention is to reposition the urethra and/or create a backboard of support to stabilize it 1. In years past surgery involved a somewhat major operation, sometimes with an abdominal incision and many weeks of recuperation. In recent years the development of minimally invasive mid-urethral slings to achieve the urethral support has come into vogue. These procedures are often done as day surgery and the recovery time is very minimal. Periurethral bulking agents involved injecting a substance under cystoscopic guidance Dickinson Urinary Incontinence Page 11

14 in an attempt to co apt the urethra. This therapy is typically performed in the office and can be a good option for those who are not surgical candidates. In refractory overactive bladder and/or urge urinary incontinence that does not respond to the other therapies discussed, sacral nerve stimulation may be the next step. This type of neuromodulation almost functions as a pacemaker for the bladder. An electrode is placed at the sacral nerves and is attached to a pulse generator that is set in the subcutaneous tissue of the buttocks. In Closing Urinary incontinence is a significant health issue. It can affect every aspect of a person s life. It is not a normal part of aging and can be effectively treated with a variety of therapies that do not always end in surgery. Case Study Concluded An urologist comes to evaluate the patient. On vaginal exam she is noted to have very pale, thin, atrophic mucosa despite being on oral hormone replacement therapy. A urinary tract infection and an elevated post void residual were ruled out. The urologist consults you on available local topical hormone replacement therapy, anticholinergic medication on formulary at the hospital. A bedside commode chair with a raised seat is ordered since mobility was impaired and stool softeners to avoid constipation. She was also instructed in adequate fluid intake to avoid concentrated irritating urine. Upon follow-up at the urologist office some months later she is thankful for being liberated from her ties to the bathroom so she can continue to live and enjoy her retirement years. Dickinson Urinary Incontinence Page 12

15 References 1 Newman D. Managing and Treating Urinary Incontinence. Health Professions Press; Baltimore, Vulker R. International Group Seeks to Dispel Incontinence Taboo. JAMA, 1998, No 11: Merriam Webster Online Dictionary: Retrieved June 7, Melville JL, Katon W, Delaney K, Newton K. Urinary Incontinence in US Women. Arch Intern Med, 2005, 165: Palmer MH. Nurses knowledge and beliefs about continence interventions in long term care. Journal of Adv Nursing, 1995, 21: The Simon Foundation for Continence website: Retrieved September 12, The Initiative for the Defeat of Stigma website: Retrieved September 28, Dickinson Urinary Incontinence Page 13

16 8 The National Association for Continence website: Retrieved September 12, Sampselle CM, Wyman JF, Thomas KK, Newman DK, Gray M, Dougherty M, Burns PA. Continence for Women: A test of AWHONN s Evidence-Based Protocol in Clinical Practice. Journal of Obstetric, Gynecologic and Neonatal Nursing, 200, 29(1): Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A. The Standardization of Terminology of the Lower Urinary Tract: Report from the Standardization Sub-Committee of the International Continence Society. Neurourology and Urodynamics, 21: (2002). 11 Wilson L, Brown JS, Shin GP, Luc KO, Subak LL. Annual Direct Costs of Urinary Incontinence. Obstetrics and Gynecology. 2001; 98: Muller N. What Americans Understand and How They are Affected by Bladder Control Problems: Highlights of Recent Nationwide Consumer Research. Urologic Nursing 2005: 25 (2): Hunskaar S, Burgio K, Diokno AC, Herzog AR, Hjalmas K, Lapitan MC. Epidemiology and the Natural History of Urinary Incontinence In: Abrams P, Cardozo L, Khoury S, Wein A, editors. 2 nd International Consultation on Incontinence. Plymouth England: Health Publication Limited, 2002; Dickinson Urinary Incontinence Page 14